Evaluating the Use of Unfractionated Heparin with Intra-Aortic Balloon Counterpulsation

BACKGROUND

Evidence supporting anticoagulation with unfractionated heparin (UFH) in patients with an intra-aortic balloon pump (IABP) to prevent limb ischaemia remains limited, while bleeding risks remain high. Monitoring heparin in this setting with anti-factor Xa (anti-Xa) is not previously described.

OBJECTIVES

The study objective is to describe the incidence of thromboembolic and bleeding events with the use of UFH in patients with an IABP utilising monitoring with both anti-Xa and activated partial thromboplastin time (aPTT).

METHODS

This is a retrospective study of adults who received an IABP and UFH for ≥24 hours. Electronic medical records were reviewed for pertinent data. The primary outcome was the incidence of limb ischaemia during IABP. Secondary outcomes included myocardial infarction, thrombus on IABP, or stroke. Exploratory outcomes included any venous thromboembolism and bleeding events.

RESULTS

Of 159 patients, 88% received an IABP for cardiogenic shock and median duration of IABP support was 118 hours (interquartile range, 67-196). Limb ischaemia occurred in four of 159 patients (2.5%). Strokes occurred in 3.8% of the cohort, and bleeding events occurred in 33%. Despite anticoagulation use in all patients, 11% experienced a venous thromboembolism, with most identified upon asymptomatic screening with concern for heparin-induced thrombocytopenia. We found no differences in outcomes that occurred with a hybrid anti-Xa and aPTT versus aPTT monitoring alone.

CONCLUSIONS

We observed a high rate of thrombotic and bleeding complications with the use of UFH in patients with an IABP. Use of anti-Xa versus aPTT for monitoring was not associated with complications. These data suggest safer anticoagulation strategies are needed in this setting.

To PLEX or Not to PLEX for Amiodarone-Induced Thyrotoxicosis

Amiodarone-induced thyrotoxicosis (AIT) carries significant cardiovascular morbidity. There are two types of AIT with treatment including antithyroid medications and corticosteroids and treatment of ventricular arrhythmias. Therapeutic plasma exchange (TPE) also known as "PLEX" may help remove thyroid hormones and amiodarone. We report a case of PLEX in an attempt to treat cardiogenic shock secondary to AIT. This case highlights the robust rapidly deleterious demise of AIT, specifically in patients with decompensated heart failure. The decision to PLEX or not to PLEX for AIT should be individualized, prior to definitive therapy.

Bilateral Vestibular Loss in Vertebrobasilar Dolichoectasia

Bilateral vestibular loss (BVL) is a relatively uncommon syndrome that may produce problems of balance; unsteady gait, especially in the dark; and visual disorders and/or oscillopsia associated with walking and head movements. Sometimes patients with BVL remain asymptomatic. Ototoxic drugs are the most frequently identified cause of BVL, but there are many other possible causes. The aetiology remains unknown in a large percentage of patients. In some, vascular aetiology may be suspected. Here we report 4 cases of vertebrobasilar dolichoectasia (VBD) and symptomatic BVL. In 3 subjects, hearing was preserved, but in the 4th, there was retrolabyrinthine hearing loss. In our opinion, VBD may be the cause of BVL associated or not associated with hearing loss, the reason being that since the anterior vestibular artery is small and has no anastomoses, the horizontal semicircular canal is selectively susceptible to ischemia.